OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: 08-31-2018
REHABILITATION NEEDS INVENTORY (RNI)
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., to determine entitlement to vocational rehabilitation benefits and to plan a program of rehabilitation services) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information for educational and vocational planning to help you make the best use of your vocational rehabilitation benefits. Title 38, United States Code chapter 31, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
1. NAME (First, middle, last) |
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2. TELEPHONE NUMBER(S) |
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HOME PHONE NUMBER |
CELL PHONE NUMBER |
WORK PHONE NUMBER |
3. CURRENT ADDRESS |
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4a. E-MAIL ADDRESS 1 |
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4b. E-MAIL ADDRESS 2 |
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5. GENDER |
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6. MARITAL STATUS |
7. CLAIM NUMBER |
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8. SOCIAL SECURITY NUMBER |
MALE |
FEMALE |
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9. CLAIMING DEPENDENTS? |
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10. NICKNAME/AKA |
11. EMERGENCY CONTACT INFORMATION |
YES |
NO # |
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CONTACT NAME |
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CONTACT PHONE NUMBER |
CONTACT RELATIONSHIP |
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12.HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?
13.WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN?
14.HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
14A. HAVE YOU EVER PARTICIPATED IN A PROGRAM OF VOCATIONAL REHABILITATION BEFORE?
YES NO
(If "Yes," complete Items 14B and 14C)
14B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
WORKER'S COMP |
PRIVATE |
STATE VOCATIONAL REHABILITATION |
OTHER (Please explain) |
VA VOCATIONAL REHABILITATION |
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14C. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED (i.e., training, medical, vocational testing, functional capacities, job search activities):
EMPLOYMENT
Please fill out each area as completely as possible. If you have a resume, please attach it.
15.CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
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COMPANY NAME |
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STATUS |
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A |
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TEMPORARY ASSIGNMENT OR CONTRACT |
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PART TIME |
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PERMANENT POSITION |
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FULL TIME |
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DESCRIBE JOB DUTIES IN DETAIL |
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REASON FOR LEAVING |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
B |
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COMPANY NAME |
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STATUS |
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TEMPORARY ASSIGNMENT OR CONTRACT |
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PART TIME |
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PERMANENT POSITION |
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FULL TIME |
VA FORM |
28-1902w |
SUPERSEDES VA FORM 28-1902w, FEB 2012, |
SEP 2015 |
WHICH WILL NOT BE USED |
15. CIVILIAN EMPLOYMENT HISTORY (CONTINUED)
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DESCRIBE JOB DUTIES IN DETAIL |
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B |
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REASON FOR LEAVING |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
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COMPANY NAME |
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STATUS |
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C |
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TEMPORARY ASSIGNMENT OR CONTRACT |
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PART TIME |
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PERMANENT POSITION |
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FULL TIME |
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DESCRIBE JOB DUTIES IN DETAIL |
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REASON FOR LEAVING |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
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COMPANY NAME |
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STATUS |
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D |
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TEMPORARY ASSIGNMENT OR CONTRACT |
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PART TIME |
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PERMANENT POSITION |
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FULL TIME |
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DESCRIBE JOB DUTIES IN DETAIL |
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REASON FOR LEAVING |
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16. MILITARY WORK HISTORY: What did you do in the military? Please fill out the following area as completely as possible. |
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Please start with your last assignment. |
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HIGHEST RANK ACHIEVED: |
ARMED SERVICES: |
ARMY |
NAVY |
AIR FORCE |
MARINES |
COAST GUARD |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
A |
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LIST ANY HONORS AND COMMENDATIONS |
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RANK |
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DESCRIBE JOB DUTIES IN DETAIL |
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HIGHEST RANK ACHIEVED: |
ARMED SERVICES: |
ARMY |
NAVY |
AIR FORCE |
MARINES |
COAST GUARD |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
B |
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LIST ANY HONORS AND COMMENDATIONS |
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RANK |
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DESCRIBE JOB DUTIES IN DETAIL |
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HIGHEST RANK ACHIEVED: |
ARMED SERVICES: |
ARMY |
NAVY |
AIR FORCE |
MARINES |
COAST GUARD |
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JOB TITLE |
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DATES |
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AVERAGE GROSS |
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FROM |
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TO |
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MONTHLY SALARY |
C |
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LIST ANY HONORS AND COMMENDATIONS |
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RANK |
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DESCRIBE JOB DUTIES IN DETAIL |
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17. WOULD IT BE POSSIBLE FOR YOU TO RETURN TO WORK IN A FORMER OCCUPATION OR FOR A FORMER EMPLOYER? |
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YES |
NO |
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VA FORM 28-1902w, SEP 2015 |
Page 2 |
MILITARY WORK HISTORY (CONTINUED)
18.WHAT WORK SKILLS DID YOU USE IN YOUR PREVIOUS POSITIONS THAT YOU THINK YOU MAY BE ABLE TO USE IN A NEW JOB?
19.PLEASE EXPLAIN WHAT YOU DID DURING PERIODS OF UNEMPLOYMENT 3 MONTHS OR LONGER:
EDUCATION AND TRAINING
Please fill out the area below regarding your education/training background as completely as possible.
Please include vocational, college, on-the-job, and other training. NOTE: Please include civilian and military schools/training.
20. MARK HIGHEST LEVEL COMPLETED:
SOME HS - HIGHEST GRADE COMPLETED:
MASTER 
DOCTORAL
21B. DATES (MM/YYYY)
FROM TO
21D.
CREDITS/
CLOCK
HOURS
21E. MAJOR COURSE
OF STUDY
21F. DEGREE (if any),
YEAR RECEIVED
22A. WHAT SUBJECTS DID YOU LIKE? |
22B. WHAT SUBJECTS DID YOU DISLIKE? |
23A. DO YOU HAVE ANY CURRENT VOCATIONAL CERTIFICATES AND/OR LICENSES?
YES 
NO
(If "Yes," complete Items 23B and 23C)
23B. LIST CERTIFICATES/LICENSES |
23C. DATE |
(Apprentices or journeyman card, truck driver/CDL, etc.) |
EXPIRES |
1
2
3
24. HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY? (If "Yes," please describe below):
DISABILITIES
List and describe your service-connected disability(ies). Please list the disability(ies) in order of severity.
25A. SERVICE-CONNECTED DISABILITY
25C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
DISABILITIES?
26A. NON SERVICE-CONNECTED
DISABILITY
26C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
DISABILITIES?
27. HAS YOUR SERVICE-CONNECTED DISABILITY(IES) AFFECTED YOU IN THE FOLLOWING AREAS OF WORK? (Check all that apply)
JOB PERFORMANCE |
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JOB OPPORTUNITIES |
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CO-WORKER RELATIONS |
OTHER (Please explain) |
JOB SATISFACTION |
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MISSED WORK TIME |
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MANAGER RELATIONS |
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VA FORM 28-1902w, SEP 2015 |
Page 3 |
31. DO YOU RECEIVE ANY OF THE FOLLOWING? (Check all that apply)
RETIREMENT (Military/civilian)
DISABILITY PENSION (Military/civilian)
UNEMPLOYMENT
WORKERS COMPENSATION BENEFITS
SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)
ALIMONY/CHILD SUPPORT
WELFARE ASSISTANCE
MEDICARE/MEDICAID
OTHER
32. DO YOU HAVE A CLAIM PENDING FOR ANY OF THE FOLLOWING? (Check all that apply)
RETIREMENT (Military/civilian)
DISABILITY PENSION (Military/civilian)
UNEMPLOYMENT
WORKERS COMPENSATION BENEFITS
SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)
ALIMONY/CHILD SUPPORT
WELFARE ASSISTANCE
MEDICARE/MEDICAID
OTHER
MEDICAL TREATMENT
Please describe medical treatment you have received or are receiving.
33B. NAME OF VA OR PRIVATE
MEDICAL FACILITY
33C. HOW OFTEN SEEN
FOR TREATMENT
33D. MEDICATION(S) PRESCRIBED
34A. DO YOU HAVE MEDICAL NEEDS |
34B. WHAT DO YOU NEED? |
THAT ARE NOT BEING MET? |
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YES |
NO |
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(If "Yes," complete Item 34B) |
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35A. DO YOU USE ANY ADAPTIVE |
35B. PLEASE DESCRIBE YOUR ADAPTIVE EQUIPMENT |
EQUIPMENT SUCH AS BRACES, |
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ARTIFICIAL LIMBS, HEARING AIDS, |
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ETC? |
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YES |
NO |
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(If "Yes," complete Item 35B) |
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36A. ARE THERE OTHER PROBLEMS |
36B. PLEASE LIST OTHER PROBLEMS OR ISSUES WITH WHICH YOU WOULD LIKE HELP |
OR ISSUES WITH WHICH YOU |
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WOULD LIKE HELP? |
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YES |
NO |
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(If "Yes," complete Item 36B) |
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37. DO YOU HAVE ANY PENDING VA CLAIMS?
YES |
NO (If "Yes," please describe below) |
38. DO YOU NEED INFORMATION ABOUT OTHER VA BENEFITS OR PROGRAMS?
YES |
NO (If "Yes," please describe below) |
MISCELLANEOUS
The following information will be used for employment planning purposes.
39A. DO YOU:
RENT
OWN
OTHER
39B. DO YOU HAVE STABLE HOUSING AT PRESENT?
YES 
NO
(If "No," complete Item 39C)
39C. DESCRIBE YOUR CURRENT LIVING SITUATION:
40A. WHAT MODE OF TRANSPORTATION DO YOU USE?
40B. HOW FAR ARE YOU WILLING TO COMMUTE FOR WORK AND/OR SCHOOL?
40C. DO YOU HAVE A VALID DRIVER'S LICENSE?
YES NO
VA FORM 28-1902w, SEP 2015 |
Page 4 |
MISCELLANEOUS (CONTINUED)
41. ARE YOU WILLING TO RELOCATE FOR A JOB?
42. IF YOU HAVE HAD A HISTORY OF OR ARE CURRENTLY DEALING WITH LEGAL ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
BANKRUPTCY |
MISDEMEANOR |
FELONY |
PROBATION |
PAROLE |
OTHER |
N/A |
43. IF YOU HAVE HAD AND/OR PRESENTLY HAVE SUBSTANCE ABUSE ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
ALCOHOL |
DRUGS (Illicit) |
DRUGS (Prescription) |
OTHER |
44. IF YOU HAVE A HISTORY OF OR ARE CURRENTLY IN ON-GOING TREATMENT(S) FOR SUBSTANCE ABUSE(S), PLEASE DESCRIBE BELOW:
45. DID ANYONE HELP YOU COMPLETE THIS FORM?
YES
NO
PROTECTION OF PRIVACY INFORMATION STATEMENT
(For use by counselees and rehabilitation program participants)
I have been informed and understand that the information requested in this and any later interviews is requested under the authorization of Title 38, United States Code, 1.576, Veterans Benefits. This information is needed to assist in vocational and educational planning, to authorize my receipt of rehabilitation services, to develop a record of my vocational progress, and to assure I obtain the best results from my rehabilitation program. I understand that the information I provide will not be used for any other purpose and that my responses may be disclosed outside the VA only if the disclosure is authorized under the Privacy Act of 1974, including the routine uses identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA, published in the Federal Register. Generally, disclosures under the authority of a routine use will be made to develop my claim for vocational rehabilitation benefits under title 38, United States Code.
My giving the requested information is voluntary. I understand that the following results might occur if I do not give this information:
(1)I may not receive the maximum benefit either from counseling or from my education or rehabilitation program.
(2)If certain information is required before I may enter a VA program, my failure to give the information may result in my not receiving the education or rehabilitation benefit for which I have applied.
(3)If I am in a program in which information on my progress is required, my failure to give this information may result in my not receiving further benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be entitled.
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
SIGNATURE OF CASE MANAGER OR VOCATIONAL REHABILITATION COUNSELOR (VRC)
VA FORM 28-1902w, SEP 2015 |
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